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PATIENT NAME:
ADMISSION DATE:
DISCHARGE DATE:
MEDICAL RECORD #:
XXXX XXXXXX
XX/XX/XX
XX/XX/XX
XXXXXXX
ADMITTING DIAGNOSIS: Reactive airway disease.
DISCHARGE DIAGNOSIS: Reactive airway disease.
HISTORY OF PRESENT ILLNESS: The patient is a 19-month-old African-American male who
had been well until 2 days prior to admission, when he developed a loose cough. Mother gave
him an over-the-counter children’s cough remedy several times each day. He was afebrile during
this time. During the day, the child had increased difficulty breathing, and wheezing was noted in
the late p.m., when the child was brought to the emergency room.
In the emergency room, the child was found to have a fever of 102°F rectally. He was found to
be in respiratory distress and was given Ventolin nebulization and admitted.
PHYSICAL EXAMINATION: Physical examination showed a patient sitting in bed with mild
respiratory distress. He was alert. Respiratory rate was 40, heart rate was 115, temperature was
102.3°. Right tympanic membrane was slightly erythematous. There was slight nasal flaring.
Throat was slightly injected. On auscultation, the lungs were found to have diffuse inspiratory
and expiratory wheezes. The heart showed the presence of normal heart sounds with mild
tachycardia.
HOSPITAL COURSE: Reactive airway disease. The patient was admitted, started on
theophylline, given a bolus of theophylline 1 mg/kg and subsequently put on a maintenance dose
of theophylline. High-flow nebulization was also given p.o. every 2 hours.
With this management, the patient showed rapid improvement and his respiratory treatments
were gradually spaced out so that, subsequently, the regimen was changed to oral medication of
theophylline. Theophylline levels were monitored during the hospital course.
DISPOSITION: The child was discharged after a 1 week hospitalization on theophylline therapy.
Condition at time of discharge was improved. Mother was instructed to bring him to our office in
1 week.
_____________________________
XXXX XXXXXX, MD
XX/EC
D: XX/XX/XX
T: XX/XX/XX